To Refer or Not To Refer: Sleep Evaluation is the Question
Shanna Diaz, DO Adult and Geriatric Psychiatry Sleep Medicine University of New Mexico Hospital November 11, 2016 Objectives
• Have a basic understanding of different sleep disorders • Know risk factors associated with different sleep disorders • Be aware of common signs and symptoms associated with sleep disorders • Understand when a sleep evaluation referral is needed Common Sleep Problems in Developmentally Delayed Individuals • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Insomnia • Hypersomnia • Parasomnias • Sleep Related Movement Disorders Contributors to Sleep Disorders
• Intrinsic brain abnormalities • Brain chemicals (neurotransmitters) of sleep and wake • Circadian rhythm Modulators • Superchiasmatic Nucleus • Melatonin Regulation • Homeostasis Modulators • Sleep Pressure • Autonomic Nervous System • Hormone regulation • Cortisol • Testosterone • Estrogen • Seizures • Breathing centers in brain stem • Messages about when and how to breathe Contributors to Sleep Disorders
• Medical illnesses • Obesity • Airway Obstruction • Diminished Breathing Effort • Cardiac Disease • Arrhythmias • Central Sleep Apnea • Pulmonary disease • Hypoxemia • Hypercarbia • Diabetes Mellitus • Energy Metabolism • Kidney Disease • Fluid Balance • Pain • Hyperarousal • Restlessness • Seizures • Hyperarousal Contributors to Sleep Disorders
• Other primary sleep disorders • Obstructive Sleep Apnea • Central Sleep Apnea • Circadian Rhythm Disorders • Parasomnias • Movement disorders Contributors to Sleep Disorders
• Medications • Sedating Medications • Anti-seizure medications • Hypertension medications • Muscle relaxants • Sleep aids • Stimulant Medications • Stimulants • Modafinil • Caffeine • Antidepressants • Psychotropic Medications • Antipsychotics • Antidepressants • Anti-anxiety medications Contributors to Sleep Disorders
• Psychiatric and Behavioral factors • Anxiety • Depression • Obsessive Compulsive Behaviors • Cognitive Problems • Caregiver Interactions Common Sleep Problems in Developmentally Delayed Individuals • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Insomnia • Hypersomnia • Parasomnias • Sleep Related Movement Disorders Obstructive Sleep Apnea
• Repeated pauses in breathing interrupting sleep • At least 10 second duration • Oxygen desaturation • Brain interruption • Associated with many medical and behavioral problems • Risk Factors: • Body Habitus • Facial Features • Muscle Tone Sleep Apnea Cycle
• Physiologic stressors: • Cyclic hypoxemia • 11,911 adults –41% systemic hypertension • Strenuous respiration • Sympathetic activation • Reduced total sleep time
Tkacova, Eur Respir J. 2014
Untreated Sleep Apnea 1868 subjects followed 20 years
Incidence of multiple organ diseases higher in OSA Group: 32% with OSA 68% without OSA
• Hypertension: 79% 25% • Coronary heart disease: 56% 24% • Pulmonary heart disease: 6% 4% • Stroke: 27% 7.5% • Diabetes: 12% 5.4%
Ci SP, 2011 (Article in Chinese) Signs/Symptoms May Vary With Age
• Children • Pauses in breathing • Secondary enuresis • Hyperactivity • Morning headache • Middle Age • Pauses in breathing • Snoring • Excessive daytime sleepiness • BMI > 35, Neck > 16/17 • Older > 60 years • Not feeling well rested • Nocturia ≥ 3 Obstructive Sleep Apnea Symptom: SNORING
• Children • 10% • Age 30 • 20% men • 5% women • Age 60 • 60% men 20-35% of habitual snorers have • 40% women OSA Physical Findings on Exam Which May Predispose to OSA
BMI > 35 Neck Circumference • > 16 in women • > 17 in men Physical Findings on Exam Which May Predispose to OSA
• Crowded Oropharynx • High arched narrow palate • Low laying palate • Large uvula • Narrow posterior oropharynx • Tonsillar hypertrophy
http://yoursmileyourstyle.com/files/2014/05/What-your-dentist-looks-for-in-diagnosing-sleep-apnea.jpg Physical Findings on Exam Which May Predispose to OSA
• Chronic nasal congestion • Nasal speech • Obligate mouth breather • adenoidal hypertrophy • Mandibular retrognathia • Floppy Eye Syndrome • AKA Ectropion • 38/45 patients (85%) had OSA • 65% had severe OSA
http://www.imo.es/wp-content/uploads/2011/02/ectropion-antes.jpg STOP-BANG: Quick Screening Tool for OSA
http://firstlighthealthsystem.org/wp-content/uploads/2016/04/Stop-Bang.jpg OSA Summary
Most Common Symptoms: • Snoring • Pauses in Breathing • Excessive Daytime Sleepiness Treat to Reduce Morbidities: • Cardiovascular • Neurological • Behavioral Common Sleep Problems in Developmentally Delayed Individuals • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Insomnia • Hypersomnia • Parasomnias • Sleep Related Movement Disorders Biologic Clocks Influence All Circadian Rhythm Disorders
• Misalignment of internal sleep/wake rhythm and the desired (or required) time for sleep
• Desire for sleep and wakefulness at inappropriate times
• Risk Factors
• Intrinsic brain abnormalities • Blindness • Genetic predisposition Common Sleep Problems in Developmentally Delayed Individuals • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Insomnia • Hypersomnia • Parasomnias • Sleep Related Movement Disorders Insomnia
• Hard to sleep • Difficulty going to sleep • Difficulty staying asleep • Waking up too early • Poor quality sleep • Risk Factors: • Hyperarousal • Environment • Habit • Medication
Acute Insomnia
• Acute Insomnia • < 3 month duration • In isolation • Often a known stressor/cause • Comorbid to medical or mental health condition • Improves with treatment for underlying cause Chronic Insomnia
• Chronic Insomnia • > 3 months • 3+ nights per week • Subtypes: • Psychophysiological Insomnia • “Trained” by habit • Worse in usual sleep environment, better in different environment • Excessive worry about not sleeping • Idiopathic Insomnia • Longstanding and persistent • Often starts in childhood • No sustained remission Chronic Insomnia
• Paradoxical Insomnia • Sleep state misperception • Report of very little to no sleep • Appear to have normal sleep on objective measures of sleep (PSG) • Evidence of altered sleep/wake arousal system • Inadequate Sleep Hygiene • Variable sleep schedule • Daytime napping • Use of sleep-disruptive products • Caffeine, tobacco alcohol • Electronic devices Chronic Insomnia
• Behavioral insomnia of childhood • Improper sleep training or limit setting • Sleep-Onset Association Type • Dependence on specific stimulation or object to fall asleep • Limit-Setting Type • Bedtime stalling • Bedtime refusal • Poor limit setting by caregiver • Mixed Type • Combination of both Secondary Insomnias
• Insomnia due to a mental health disorder • Insomnia due to a medical condition • Insomnia due to a drug or substance Insomnia Summary
• Behavioral interventions are most • Refer if: effective • Acute Insomnia persists for unclear • Acute insomnia often resolves when reasons primary reason is resolved • Over the counter medications to help with sleep are being used • Chronic Insomnia can be nightly • Lifelong • Medications being used for • Formed by habit insomnia are not effective • Due to other medical or behavioral • Concern about underlying reason factors • OSA • Worsened by other sleep disorders • Hypoxemia • RLS • PLMD • Seizures Common Sleep Problems in Developmentally Delayed Individuals • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Insomnia • Hypersomnia • Parasomnias • Sleep Related Movement Disorders Hypersomnia
• Too Much Sleep • Excessive duration of sleep • Excessive depth of sleep • Excessive frequency of sleep episodes • Risk Factors • Intrinsic • Genetic • Medication Hypersomnia
• Narcolepsy • Narcolepsy Type I • Due to loss of orexin secreting • Cataplexy neurons • Sudden loss of muscle tone • Genetic predisposition • Precipitated by strong emotions • Autoimmune component • Retain Consciousness • Symptoms: • Narcolepsy Type II • Sleep attacks • No cataplexy • Sleep Onset latency of < 8 minutes • Sleep onset REM period • Sleep Onset hallucinations • Sleep/wake instability • Too sleepy in the day • Hard to sleep soundly during the night Hypersomnia
• Idiopathic hypersomnia • Klein-Levin Syndrome • Hypersomnia • 2-5 week duration • Recurrent at least < every 18 months • At least one during episode: • Cognitive dysfunction • Anorexia or hyperphagia • Disinhibition • Altered perception Hypersomnia
• Hypersomnia due to a • Brain tumors medical disorder • CNS infections/lesions • Parkinson’s disease • Endocrine disorders • Post traumatic • Hypothyroidism • Genetic disorders • Metabolic • Prader Willi encephalopathy • Myotonic dystrophy • Residual sleepiness in those with adequately • Moebius syndrome treated OSA • Fragile X syndrome Hypersomnia
• Hypersomnia due to a medication • Sedating medication • Substance abuse • Stimulant withdrawal • Hypersomnia associated with a psychiatric disorder • Mood disorder • Somatoform disorders • Schizoaffective disorder • Adjustment disorder • Personality disorders • Insufficient sleep syndrome • Common in teens Hypersomnia Summary
• A known factor in • Refer if: many • Concern for underlying neurodevelopmental cause syndromes due to : • OSA • Intrinsic factors • Seizures • Medical morbidities • Overmedicated • Medications • Other sleep disorders Common Sleep Problems in Developmentally Delayed Individuals • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Insomnia • Hypersomnia • Parasomnias • Sleep Related Movement Disorders Parasomnias
• Unwanted nocturnal behaviors • Simple or Complex • Routine behaviors • Inappropriate behaviors • Consciously unaware • Familial Pattern • Neither parent affected • 22% of children sleepwalk • One parent affected • 45% • Both parents affected • 60% • Predisposing, priming and precipitating factors involved NREM Parasomnias
• Often in the first third of the night • More Common in children • Typically from NREM 3 sleep • Increased with: • Sleep deprivation • Sickness • Stress • Side effects to medications Parasomnias During NREM Sleep
•Night Terrors •Episodes of abrupt terror •Intense fear •Autonomic arousal •Inconsolable •Eyes open •Brief to 30+ minutes
•Confusional Arousals •Mental confusion or confused behavior •Absence of terror or ambulation Parasomnias During NREM Sleep
• Sleep walking • Somnambulism • Sleep talking • Somniloquy • Groaning during Sleep • Catathrenia • Bedwetting • Enuresis • Teeth Grinding • Bruxism •Sleep related eating disorders •Eating while asleep •Variant of sleepwalking Parasomnias During REM Sleep
•REM Behavioral Disorder •Dream enactment •Usually Brief •Recall intact upon awaking •Themes of being pursued/fear • Associated with neurodegenerative diseases •Predate onset of Alpha- synucleinopathies by years •Parkinson’s Disease •Multiple systems atrophy •Dementia with Lewy Bodies •Lesions affecting brain stem •Multiple Sclerosis •Narcolepsy •Stroke •Medications •Antidepressants Parasomnias During REM Sleep
•Nightmares •Recall intact upon awaking •Second half of the night
•Sleep Paralysis •Awake but unable to move
•Sleep related hallucinations •Hypnogogic •When falling asleep •Hypnopompic •When waking up Parasomnia Summary:
• Parasomnias can be • Refer if: caused by: • Occur nightly • Sleep deprivation • Causing safety • Sickness concerns • Stress • Persist over long periods • Side effects to medications • Sleep disorders Common Sleep Problems in Developmentally Delayed Individuals • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Insomnia • Hypersomnia • Parasomnias • Sleep Related Movement Disorders Sleep Related Movement Disorders
• Restless Leg Syndrome U- Urge to move limbs R- Rest makes it worse G- Getting up/moving helps E- Evening or night S- Symptoms not due to other cause Sleep Related Movement Disorders
• Restless leg syndrome • Bothersome while awake • Associated with iron deficiency • Ferritin < 50 • Familial • Overlap with Periodic Limb Movements Disorder • 80% of those with RLS have PLMD Sleep Related Movement Disorders
• Periodic Limb Movement Disorder • During Sleep • Movements interrupt/worsen sleep • Overlap with RLS • 20% of those with PLMD have RLS Sleep Related Movement Disorders
• Sleep Related Rhythmic • A “problem” when: Movement Disorder • Interferes with sleep • Repetitive, stereotyped • Daytime impairment and rhythmic motor behaviors • Risk of Self Injury • Body rocking • Head banging • Leg banging • Occurs when drowsy or asleep Sleep Related Movement Disorder Summary
• RLS can mimic insomnia • Refer if: • Check ferritin level is > 50 • Daytime functional impairment • Periodic Limb Movements may • Safety concerns not be a disorder: • if not interrupting sleep • not causing daytime dysfunction • Rhythmic Movements can be a coping tool • Dream enactment may be a harbinger of a neurodegenerative illness Developmentally Delayed Populations at High Risk for Sleep Disorders • Down Syndrome • Myotonic Dystrophy • Obstructive Sleep • Obstructive Sleep Apnea Apnea- incidence of 50- 100% • Central Sleep Apnea • Insomnia • Central Hypersomnia • Prader Willi • Smith Magenis Syndrome • Obstructive Sleep Apnea • Circadian Rhythm • Central Hypersomnia Disorders • Nocturnal Eating • Insomnia • Obstructive Sleep Apnea Developmentally Delayed Populations at High Risk for Sleep Disorders • Syndromes with • Individuals with Dysmorphic Faces Blindness • Obstructive Sleep Apnea • Circadian Rhythm Disorders • Autism Spectrum • Syndromes with Epilepsy • Insomnia • Obstructive sleep apnea • Sleep related rhythmic movement disorders • Hypersomnia • Parasomnias Case: Mr. Willi
Mr. Prader-Willi is a 39 year old morbidly obese male who reports that he wakes every morning with a headache and feels tired during the day. He sleeps an average of 12 hours a night. He often wakes up hungry in the middle of the night and sneaks to the kitchen to get a snack, while other times he wakes up with crumbs in his bed though does not remember getting up to eat. His roommate complains that he is “noisy” at night, which makes Mr. Willi feel persecuted. Case: Mr. Willi: Key Points
• Some developmental disorders, like Prader-Willi, have known hypersomnia • Obesity is a risk factor for OSA • Waking unrefreshed after sufficient sleep and taking day time naps is a major red flag for OSA • OSA is a risk factor for parasomnias due to interruptions in sleep • OSA contributes to problems with glucose regulation and impulse control • Snoring may bother others more than the patient • Obesity increases the likelihood of obesity hypoventilation • Morning headache due to accumulation of CO2 due to insufficient expiration/hypoventilation • Resolves when CO2 is “blown off” with normal respirations when awake Case: Ms. Nellie
Mrs. Nellie is a 57 year old female with autism spectrum disorder who has always had insomnia and been a nervous person, but over the last several years has been having even more difficulty falling asleep and has been waking up in the middle of the night “in a panic”. She sometimes wakes and can’t move her body for several minutes, which is very frightening to her. Now she fears going to sleep. She returns for follow up after starting lorazepam 1mg at bedtime noting that she is falling asleep faster, but still wakes with anxiety. She has been having memory problems. She wakes to urinate at 3am and can’t return to sleep. Sometimes rocking her body helps her go to sleep. Case: Ms. Nellie Key Points • Rates of sleep apnea in women increase after menopause • Repeated episodes of hypoxemia and increased sympathetic response can contribute to anxiety • Sedating medications decrease muscle tone in airway and can worsen OSA • Repeated hypoxemia and sleep fragmentation contributes to short term memory problems and word finding difficulties • OSA is typically worse during REM sleep • OSA increases/causes nocturia • Rhythmic movements of sleep can be a self soothing tool for some • Warrants treatment/is a disorder if causing harm or poor sleep Case: Ms. Oxy
Ms. Oxy is a 28 year old female treated with opioid pain medications for a Chiari malformation that causes intense headaches. She has had a few “scary” episodes where her roommate wakes and thinks she is dead because she can’t see Ms. Oxy breathing. Ms. Oxy notes sometimes waking with a racing heart. She requests something to help with her anxiety at night. Case: Ms. Roxy Key Points
• Brain injuries or malformations can affect the sleep wake circuitry and breathing centers in the brainstem • Opioid medications decrease respiratory drive during sleep • Brain forgets to send a signal to lungs to breathe • Decreased capacity to arouse when hypoxemic • Concurrent use of benzodiazapines and narcotic medications are a “double whammy” • Increased OSA risk from loss of muscle tone • Central sleep apnea from blocking mu receptors Case: Mr. Stumper
Mr. Stumper is a 43 year old male with trisomy 21, hypertension and diabetes, presenting for follow up. He recently started a third antihypertensive agent and increased his long acting insulin. His blood pressure and diabetes are still poorly controlled. He has had difficulties with medication compliance in the past, and you suspect that he is not taking his medications as directed. When asked about this, he becomes very upset an leaves the office, tearful when noting that he is always the bad guy. Case: Mr. Stumper Key Points
• OSA increases risk of hypertension four fold • OSA prevents nocturnal dipping • Blood pressure usually drops 10-20% during sleep • OSA causes insulin resistance due to stress response • Also true in non-diabetics
Harding SM, J Clin Sleep Med, 2014 Case: Annie Antsy
Annie Antsy is a non-verbal 13 year old female who has recently been having agitation at bed time. She recently started menstruating She has always been a “picky” eater She was started on a mirtazapine to help her sleep, which seemed to make things even worse Case: Annie Antsy Key Points
• Restless legs can manifest as behavioral issues, especially in those not able to communicate • Iron deficiency is a cause of restless legs • Medications, especially antidepressants can cause restless legs • 30% of people on mirtazapine get RLS symptoms What questions do you have?
• Shanna Diaz D.O. • [email protected] • 505-272-0110
Special thanks to Frank Ralls, MD, program director of UNMH Sleep Medicine Fellowship, for sharing slide content References: • Tkacova R., McNicholas W. T., Javorsky M., et al. Nocturnal intermittent hypoxia predicts prevalent hypertension in the European Sleep Apnoea Database cohort study. European Respiratory Journal. 2014;44(4):931–941. doi: 10.1183/09031936.00225113 • Muniesa M., Sánchez-De-La-Torre M., Huerva V., Lumbierres M., Barbé F. Floppy eyelid syndrome as an indicator of the presence of glaucoma in patients with obstructive sleep apnea. Journal of Glaucoma. 2014;23(1):e81–e85. doi: 10.1097/IJG.0b013e31829da19f. • Gopal, Manish et al. Investigating the Associations Between Nocturia and Sleep Disorders in Perimenopausal Women The Journal of Urology , Volume 180 , Issue 5 , 2063 - 2067 • Ci SP1, Gao Y, Zhang XL, Mao JH, Zhao NZ, Ni JQ, Shen X, Ding M, Xu XX. Twenty years follow-up: the correlation between sleep apnea syndrome and cerebrovascular disease]. Zhonghua Jie He He Hu Xi Za Zhi. 2011 Jan ;34(1):13-6. • Harding SM. Resistant hypertension and untreated severe sleep apnea: slowly gaining insight. J Clin Sleep Med 2014;10(8):845- 846. • Walia HK, Li H, Rueschman M, et al., authors. Association of severe obstructive sleep apnea and elevated blood pressure despite anti-hypertension medication use. J Clin Sleep Med. 2014;10:835–43 • Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046–53. • Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med. 2005;172:1447–1451 • Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V.. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med (2005) 353:2034–41.10.1056/NEJMoa043104 • Munoz R, Durán-Cantolla J, Martínez-Vila E, Gallego J, Rubio R, Aizpuru F, et al. Severe sleep apnea and risk of ischemic stroke in the elderly. Stroke. 2006. September;37(9):2317–21. • Grimm W., Sass J., Cassel W., Hildebrandt O., Apelt S., Nell C., Koehler U. Severe central sleep apnea is associated with atrial fibrillation in patients with left ventricular systolic dysfunction. Pacing Clin. Electrophysiol. [(accessed on 5 September 2014)]. doi:10.1111/pace.12495. • Kauta SR, Keenan BT, Goldberg L, Schwab RJ. Diagnosis and treatment of sleep disordered breathing in hospitalized cardiac patients: a reduction in 30-day hospital readmission rates. J Clin Sleep Med. 2014;10:1051–9. • See comment in PubMed Commons belowVizzardi E1, Curnis A, Latini MG, Salghetti F, et al. Risk factors for atrial fibrillation recurrence: a literature review. J Cardiovasc Med (Hagerstown). 2014 Mar;15(3):235-53. doi: 10.2459/JCM.0b013e328358554b. • Gilat H, Shpitzer T, Guttman D, et al. Obstructive sleep apnea after radial forearm free flap reconstruction of the oral tongue. Laryngoscope. 2013;12:3223–3226.